Neutrophil lymphocyte ratio: a prognostic marker in acute ST elevation myocardial infarction

Objective: To investigate if neutrophil lymphocyte ratio [NLR] predicts in-hospital adverse events and mortality, and shortterm [30-day] mortality in ST-elevated myocardial infarction [STEMI] patients thrombolysed with streptokinase [SK]

Study Design: An observational study

Place and Duration of Study: Rawalpindi Institute of Cardiology, from June 2014 till January 2015

Methodology: The STEMI patients, thrombolysed with SK had blood samples at admission, analysed for complete blood counts and NLR calculated. They were grouped into two, low and high NLR, taking 4.50 as cut-off. Chi square test was used to compare rate of adverse events and death in hospital stay. Mann-Whitney test was used to compare median NLR between patients died and discharged alive. Logistic regression analysis was used to estimate predictive ability of NLR for 30-day mortality

Results: A total of 145 [45.3%] patients had complications; 49 [15.3%] died in hospital, and 13 [4.06%] died in 30 days. Patients in high NLR group had higher rate of complications [63.5% vs. 25.5%, p <0.0001] and death [19.2% vs. 11.1%, p=0.046] in hospital than those in low NLR group. Cardiogenic shock [27.5% vs.11.1%, p <0.0001], heart failure [19.2% vs. 7.2%, p=0.002], arrhythmias [18% vs. 6.5%, p <0.0001], reinfarct/angina [9.6% vs.2% p=0.004] occurred more in high NLR group. Median NLR in patients died was higher than those discharged alive [7.46 vs. 4.70, p <0.0001]. Regression analysis showed NLR an independent predictor of mortality [OR 1.131 at 95% CI, p = 0.029]. Age, serum creatinine, Killip class were other predictors [p=0.002 and p=0.02, respectively]. ROC curve showed AUC 0.908 [p <0.0001]

Conclusion: A high NLR predicted increased in hospital complication rate, and in-hospital as well as 30-day mortality in STEMI patients thrombolysed with streptokinase

Peripartum cardiomyopathy in a Pakistani cohort

Objective: To describe the demographics, risk factors, and clinical presentation in Pakistani patients with peripartum cardiomyopathy

Study Design: A descriptive observational study

Place and Duration of Study: Rawalpindi Institute of Cardiology, Rawalpindi, from June 2014 to June 2015

Methodology: Seventy patients meeting criteria of peripartum cardiomyopathy were included in the study. A detailed history, physical examination and investigations were done. Epidemiologic data, risk factors, New York Heart Association [NYHA] class and echocardiographic findings were recorded. Statistical analyses were done using SPSS version 19

Results: The mean age was 28.66 +/-4.57 years. Mean parity and weight was 3.04 +/-1.7 and 60.97 +/-12.40 Kg, respectively. Fifty-five [78.6%] cases were diagnosed in the postpartum period. Thirty-three [50.8%] and 31 patients [44.7%] presented in NYHA - III and IV classes, respectively. Pregnancy-induced hypertension was seen in 16 [22.9%] cases, diabetes in 6 [8.6%], and twin pregnancy in 2 [2.9%] cases. The mean hemoglobin and brain natriuretic peptide [BNP] was 11.26 +/-1.61 gm/dl and 1583.70 +/-1237.65 pg/ml, respectively. Echocardiography showed mean ejection fraction of 21.74 +/-7.45%. Left ventricle systolic and diastolic diameters were 53.71 +/-9.74 mm and 63.37 +/-8.48 mm, respectively

Conclusion: Peripartum cardiomyopathy was seen in younger women with higher parity and pregnancy induced hypertension, often manifesting in the postpartum period with NHYA class III and IV status

Clinical safety and parameters of maximum oxygen uptake [VO[2] max] testing in Pakistani patients with heart failure

To determine the parameters of maximum oxygen uptake [VO[2] max] in a Pakistani systolic heart failure cohort and its safety in a clinical setting. Descriptive study. Armed Forces Institute of Cardiology, National Institute of Heart Diseases, Rawalpindi, from June 2011 to January 2013. Maximum oxygen uptake test was performed in patients with severe heart failure, who could perform the VO[2] max treadmill test. Age, Body Mass Index [BMI] ejection fraction, VO[2] max and respiratory exchange ratios and their correlations were determined. Out of 135 patients, 77% [n=104] were males, with a mean age of 45.9 +/- 15.7 years. Weight of patients ranged from 30 kg to 107 kg [mean 63.29 +/- 13.6 kg]; mean BMI was 23.16 +/- 4.56 kg/m2. All patients presented with either NYHA class of III [50.3%; n=68] or IV [49.7%; n=67]; mean ejection fraction was 22.54 +/- 5.7% [10 - 35%, IQ:20 - 25]. The VO[2] max of the patients ranged from 3 to 32 ml/kg/minute [mean 12.85 +/- 4.49 ml/kg/minute]. Respiratory exchange ratio was over 1 for all patients [1.12 - 1.96, mean = 1.36 +/- 0.187]. There was a negative correlation with age [r = 0.204; p = 0.028] whereas a positive correlation was found with exercise time [r = 0.684; p = 0.000], hemoglobin [r = 0.190; p = 0.047] and ejection fraction [r = 0.187; p = 0.044]. Cardiopulmonary exercise testing in a high-risk heart failure cohort is safe and provides information beyond the routine clinical evaluation of heart failure patients

Description and follow-up of patients with coronary perforations during percutaneous coronary interventions at AFIC-NIHD

This study was conducted to determine the frequency and describe the lesion characteristics, clinical factors, device responsible and outcomes for coronary perforations at Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC -NIHD] on all patients undergoing percutaneous coronary interventions [PCI] from 2007 to May 2012. A total of 13,366 PCI procedures were performed during this period; coronary perforation occurred in 16 cases [0.001%]. All patients had elective PCI. Fifty percent [n = 8] patients had type C lesions. Grade III perforations were seen in 10 patients. Seven perforations were caused by angiography wires. None of the perforations was related to atherectomy devices. Six patients needed pericardiocentesis. There were 3 in-hospital deaths. One patient needed CABG. At followup, all patients who had been discharged were alive. The frequency of coronary perforations was very low. Old age and type C lesions were identified as a risk factor for coronary perforations. Grade III [or greater] perforation was a predictor of mortality. Patients who are discharged to home generally had better outcomes.

Validation of the Seattle heart failure model [SHFM] in heart failure population

To determine the effectiveness of Seattle Heart Failure Model [SHFM] in a Pakistani systolic heart failure cohort in predicting mortality in this population. Cohort study. The Armed Forces Institute of Cardiology - National Institute of Heart Diseases, Rawalpindi, from March 2011 to March 2012. One hundred and eighteen patients with heart failure [HF] from the registry were followed for one year. Their 1-year mortality was calculated using the SHFM software on their enrollment into the registry. After 1-year predicted 1-year mortality was compared with the actual 1-year mortality of these patients. The mean age was 41.6 A +/- 14.9 years [16 - 78 years]. There were 73.7% males and 26.3% females. One hundred and fifteen patients were in NYHA class III or IV. Mean ejection fraction in these patients was 23 A +/- 9.3%. Mean brain natriuretic peptide levels were 1230 A +/- 1214 pg/mL. Sensitivity of the model was 89.3% with 71.1% specificity, 49% positive predictive value and 95.5% negative predictive value. The accuracy of the model was 75.4%. In ROC analysis, AUC for the SHFM was 0.802 [p < 0.001]. SHFM was found to be reliable in predicting one-year mortality among patients with heart failure in the Pakistani patients

Superior vena cava thrombosis with peripartum dilated cardiomyopathy

A 30 years multiparous female with history of emergency caesarean section 10 days back was referred to us with cough, severe breathlessness at rest, orthopnea with pain in neck and arms. Clinical examination revealed signs of heart failure. Echocardiography showed ejection fraction of 15%, with no right ventricular strain. A diagnosis of peripartum cardiomyopathy was made. Doppler ultrasound of neck veins showed bilateral internal jugular vein thrombosis. Subsequent multislice CT examination showed thrombosis of superior vena cava and both internal jugular veins [with collateral formation] and pulmonary embolism. There were no mediastinal abnormalities on the CT scan. Her thrombophilia screen and CT scan brain was normal. She was managed in collaboration with cardiologist. Following treatment with subcutaneous enoxaparin therapy and warfarin her symptoms of upper limb pain improved. She responded very well to medical therapy for heart failure with marked improvement of NYHA functional class

Trans-radial primary percutaneous coronary intervention in ST-elevation myocardial infarction

To study the effect of trans-radial approach [TRA] on achievement of a door-to-balloon time [DBT] of

Effect of a regimen of optimal medical therapy on brain natriuretic peptide [bnp] levels in heart failure in the Pakistani population

To document the effect of optimal medical therapy [OMT] on BNP levels in heart failure in Pakistani population. In this Quasi experimental study, 75 consecutive stage C heart failure patients that had not been on OMT were included. These patients had been referred to AFIC-NIHD Heart Transplantation Department for assessment regarding heart transplantation. Initial assessments were carried out in hospital. Patients who were on OMT already were excluded. The prescription [carvedilol, lisinopril, spironolactone] was introduced as in patient as per pre defined protocol after clinical, imaging and lab evaluation. The patients were followed up in clinic and the dose escalation was done at regular intervals in out patients department. Clinical and lab variables were collected included BNP levels before starting treatment and 4 weeks after treatment. Males were 75% and females were 25%. Mean age was 38.69 +/- 12.98 years [range 18-70 years]. Mean Ejection fraction was 23.9% [range 15 - 34%]. At one month clinical status of all patients improved except one. The patients had improved from NYHA class-III to NYHA class-II of dyspnoea. The mean baseline BNP level was 1331 pg/ mL, and the BNP level 4 weeks after the OMT trial was 951.9 pg/mL. This reduction was statistically significant [p=0.016]. OMT improves the BNP levels within a span of one month in patients with advanced systolic heart failure. This also correlated with the clinical improvement in the patients, and it was observed that BNP levels helped to monitor patients objectively and adjust OMT

Follow up of the patients treated with the mguard stent system in percutaneous coronary intervention at AFIC- NIHD

The objective of this study was to conduct a follow up of the patients treated with the MGuard Stent used in Percutaneous Coronary Intervention [PCI] in the setting of acute coronary syndromes at AFIC-NIHD

Introduction: The consequences of distal embolisation during PCI in acute coronary syndrome can vary from a simple sluggish flow to myocardial infarction and death. A number of protection devices reduce distal embolisation, but they add complexity and cost to the procedure. The MGuard stent is a unique innovation to counter the phenomenon

Objective: The objective of this study was to conduct an angiographic follow up of the patients treated with the MGuard Stent used in Percutaneous Coronary Intervention [PCI] in the setting of acute coronary syndromes at AFIC-NIHD. Patients and Methods: The study was conducted in AFIC-NIHD. Between April 2010 to date 21 patients were treated with a total of 25 MGuard stents. Inclusion criteria included de novo lesions in saphenous vein grafts or native vessels with angiographic evidence of thrombus activity or lesion instability and a potential for distal embolization, all in the setting of acute coronary syndromes

Results: All patients were male. Mean age was 46.23 years [range 32-70 years]. All patients were admitted with acute coronary syndromes. Most lesions had complex morphological features and all had some thrombus activity. The MGuard stent was deployed successfully in all cases and without any complications. Secondary endpoints [TIMI-III flow and myocardial blush grade 3] were met in all cases. There was no elevation of cardiac enzymes post procedure in any patient.On follow up Nine patients [42%] had critical ISR [2 of these were total occlusions] and all required repeat intervention.One patient died within 30 days of PCI

Conclusion: These preliminary results show that the MGuard stent is a safe option for patients undergoing PCI in de novo coronary artery lesions in the setting of acute coronary syndrome with thrombus burden and saphenous vein graft stenosis. However the long term follow up of these patients shows significant ISR which needs to be clarified with a larger sample size

Follow up of the patients treated with the mguard stent system in percutaneous coronary intervention at afic - NIHD

The objective of this study was to conduct a follow up of the patients treated with the MGuard Stent used in Percutaneous Coronary Intervention [PCI] in the setting of acute coronary syndromes at AFIC - NIHD. The consequences of distal embolisation during PCI in acute coronary syndrome can vary from a simple sluggish flow to myocardial infarction and death. A number of protection devices reduce distal embolisation, but they add complexity and cost to the procedure. The MGuard stent is a unique innovation to counter the phenomenon. The objective of this study was to conduct an angiographic follow up of the patients treated with the MGuard Stent used in Percutaneous Coronary Intervention [PCI] in the setting of acute coronary syndromes at AFIC - NIHD. The study was conducted in AFIC - NIHD. Between April 2010 to date 21 patients were treated with a total of 25 MGuard stents. Inclusion criteria included de novo lesions in saphenous vein grafts or native vessels with angiographic evidence of thrombus activity or lesion instability and a potential for distal embolization, all in the setting of acute coronary syndromes. All patients were male. Mean age was 46.23 years [range 32-70 years]. All patients were admitted with acute coronary syndromes. Most lesions had complex morphological features and all had some thrombus activity. The MGuard stent was deployed successfully in all cases and without any complications. Secondary endpoints [TIMI - III flow and myocardial blush grade 3] were met in all cases. There was no elevation of cardiac enzymes post procedure in any patient.On follow up Nine patients [42%] had critical ISR [2 of these were total occlusions] and all required repeat intervention.One patient died within 30 days of PCI. These preliminary results show that the MGuard stent is a safe option for patients undergoing PCI in de novo coronary artery lesions in the setting of acute coronary syndrome with thrombus burden and saphenous vein graft stenosis. However the long term follow up of these patients shows significant ISR which needs to be clarified with a larger sample size

Follow up of the patients treated with the mguard stent system in percutaneous coronary intervention [pci] at afic-nihd

The objective of this study was to conduct a clinical and angiographic follow up of the patients treated with the MGuard Stent used in PCI in the setting of acute coronary syndromes. The study was conducted in AFIC-NIHD Rawalpindi, from April 2010 and October 2010 twenty one patients were treated with a total of 25 MGuard stents. Patients included were those having de novo lesions in saphenous vein grafts or native vessels with angiographic evidence of thrombus and lesion instability with a potential for distal embolization in the setting of acute coronary syndromes. All patients were male. Mean age was 46.23 years [range 32-70 years]. Fourteen patients were admitted with ST elevation MI, 4 with Non-ST elevation MI, and 3 with unstable angina. Two vein grafts were stented while the rest were de novo lesions in native coronary arteries. The mean vessel diameter was 3.0mm [2.5- 3.5]. The stent length ranged from 12 to 39 mm. MGuard stent was deployed successfully with no complications of PCI [distal embolization]. Secondary endpoints [TIMI- III flow and myocardial blush grade 3] were met in all cases. One patient died within 30 days of PCI. On follow up 9 patients [42%] had critical ISR [2 of these were total occlusions] and all required repeat intervention. Total MACE events were 47% [1 death and 9 TLR]. Angiographic follow up of MGuard stent at 6 month showed significant ISR which needs to be clarified with a larger sample size

Initial experience with the novel mguard stent system for percutaneous coronary intervention at AFIC-NIHD

To assess the efficacy of the MGuard Stent in Percutaneous coronary Intervention [PCI] in the setting of acute coronary syndromes. Interventional case series. Distal embolisation during PCI occurs in acute coronary syndrome from the thrombus occluding the artery. The consequences can vary from a simple sluggish flow to myocardial infarction and death. A number of protective devices reduce distal embolisation, but they add complexity and cost to the procedure. The balloon expandable MGuard stent is a unique innovation to counter the phenomenon. We sought to study its efficacy in the proposed indications. The study was conducted in AFIC - NIHD. Between April and July 2010, 18 patients were included and a total of 21 MGuard stents were deployed. Inclusion criteria were de novo lesions in saphenous vein grafts or native vessels with angiographic evidence of thrombus activity or lesion instability and a potential for distal embolisation in the setting of acute coronary syndromes. Use of filter wires or other proximal or distal protective devices was not allowed in the study. Primary end point included the incidence of MACE [composite if cardiac death, non-fatal MI and need for TLR] up to 30 days after the procedure. Secondary endpoints included restoration of TIMI grade 3 flow and myocardial blush grade 3 at the end of the procedure. All patients were male. Mean age was 45.61 years [range 32-70 years]. All were admitted with acute coronary syndrome. Most lesions had complex morphological features and all had some thrombus activity. The MGuard stent was deployed successfully in all cases and without any complications. Secondary endpoints [TIMI- grade III flow and myocardial blush grade 3] were met in all cases. There was no elevation of cardiac enzymes post procedures in any patient, and no MACE was reported at 30 days [primary end point]. These preliminary results show that the MGuard stent is a safe option for patients undergoing PCI in the setting of acute coronary syndrome with thrombus burden and saphenous vein graft stenosis